Opioid Prescription- The New Red Flag

I recently (here) blogged about the devastating rise in overdose deaths from prescription opioid medications. This is no longer a hidden danger in our society. President Obama has proposed $1.1 Billion to address this issue. Presidential candidates from both political parties have frequently mentioned the opioid epidemic in their stump speeches and even in their primary victories. The Centers for Disease Control have recognized this alarming epidemic as one that is largely self-induced by the medical and pharmaceutical industries. In 2012, health care providers wrote 259 million prescriptions for opioid drugs—enough for every American adult to have their own bottle of the pills! This has lead to drug overdose being the leading cause of injury death in 2013. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes.Given that the number one reason for an opioid prescription is Low Back Pain we can only describe this is as an utterly epic failure.

What is our role in reversing this process as we go forward clinically? It is well established that PT First for Low Back Pain decreases opioid use. Our continued efforts across all fronts in getting this message out to consumers, payers, and the medical community at large remains a top priority. However, what about the patient sitting right in front of you today? During your intake exam do you currently see the Oxycodone (OxyContin and Percocet), Hydrocodone (Vicodin) or Fentanyl (Duragesic) as a red flag in your history? Given the current statistics on the likelihood of overdose or death from these drugs I would urge each of us to place these drugs into the category of a red flag.

Once we identify red flags we are left with a decision of what is the next action step. As a start point let’s focus on the patient with LBP and a relatively new prescription of these drugs (4 weeks or less). The most important thing is that you must first establish trust and credibility with your patient, which is gained by exceptional communication and true environment of caring and compassion. This is not that difficult! As a side note yesterday I had the most hilarious encounter with a middle-aged patient (with a persistent pain problem) and her husband. As I was nearing completion of the visit, the husband says to me, “You have the best listening skills of anyone we have ever encountered in medicine.” Then the wife commented, “Well in medicine, that isn’t saying much!” We all laughed so hard it hurt. It is funny how humor gets at the truth of what ails healthcare. Lets get back to our patient with LBP on opioids that you have established a reasonable therapeutic alliance with. It is now time to find out the details of how and when they are taking these drugs. Once that is established shift to the open ended questions on function and pleasure such as:

Are you doing more while you are on the medications?

What things are you not doing when you are on the medications?

Do you enjoy taking the medications or would you rather not take them?

Though patient and situation dependent this is usually the time to begin probing for understanding. That again is best done with questions.

Do you know how addictive these drugs can be?

Do you think you could get addicted to these?

Are you aware that prescription overdose deaths caused more deaths than motor vehicle crashes?

This is usually enough to get the conversation started and gain an understanding of the patient’s perspective on using these drugs for their LBP. The next step is to complete the history and physical examination. A detailed examination is in itself therapeutic and increases the therapeutic alliance. At this point placing the plan of care in the context of the red flag opioid use is critical. Open discussion and framing of the situation in terms of real risk is necessary. Your plan should be very clear that a key goal is immediate reduction followed by termination of opioid medication use. In closing, I have provided a quick educational video that might be helpful for you or your patients in understanding the drawbacks of these medications. We are at a critical juncture; please provide any comments or useful suggestions to help stem this epidemic.

14 responses to “Opioid Prescription- The New Red Flag”

Great post! The bigger problem comes from those on opioids more than 2 – 3 months at a rate of 4 or more pills a day. I’m curious how others feel. My experience is that very few in this group are seeing me with a genuine desire to improve. Although this is an oversimplification, most of these patients are in my office to prove that they need the meds. Almost always, they are following MD orders so they don’t jeopardize their medication prescription. Further, conversations with the MD regarding my suspicion that the patient is exhibiting drug seeking behavior usually results in no action being taken, or simply sending the patient to another. PT. What are your experiences among this group?

Bullshit! Did you ever have chronic debilitating pain and multiple back surgeries and PT that never worked and scar tissue everywhere and arthritis everywhere and spinal stenosis, etc. Doc after docs tell you they can’t help you and without the meds that you’re furious you have to take you’re in the fetal position on the couch everyday crying your eyes out.

I have weened myself off opiates so many times I lost count thinking I beat it somehow and miraculously got healed. Put my body through hell for weeks or more. Then had to go right back on them because I couldn’t move and was hysterical.

You people simplify this situation so much it makes me so mad. Everyone’s seeking drugs. All the new DEA changes. Drs will know if patients are running out of meds too soon. Pharmacies will know if their switching drs or switching pharmacies. I still don’t believe the problem is the drs. It’s what they buy on the streets when the use up their prescribed medications. But no one wants to talk about how bad the drug problem is on the streets.

Drs can’t write crap anymore. They can’t even see over a certain amount of patients. For eight months since a serious fall needing one to three more back surgeries I found only one pain dr that could see me. I switched and was out of luck. I’m now tapering off meds again and I am a patient who really needs them in order to have any type of life. The soonest I will have even my first back surgery looks like October. I will be in excruciating pain for two months because the government blames prescription opiates and doctors for all these deaths that should be blamed on street drugs and herion. Where does a pain patient who truly needs to be on medication go when they can’t get help from doctors anymore? Has the government though about the can of worms they’re opening there with the amount of deaths they’ll cause. Because these people will wind up herion addicts and there lives will be destroyed because it a cheaper drug but will do the trick, then they’ll die a terrible death because the couldn’t see a dr.

Good job guys. You already pulled all the licenses of the bad drs and continue to do so. You already changed all the rules on the meds the drs can write regardless of whether it helps the patient or not and say try PT. WTF!!! What about all of us that are in too much pain to even do a neck lift without it causing such a flare up the the physical therapists have to work two weeks to calm it down. You know nothing about serious injuries, chronic pain or the emotional toll it takes on people.

Yes, everyone becomes dependent after long term use and it freaking sucks. But if you have no choice what do you do. Addicts are people who use there drugs up and then steal money and other things and go on the streets and steal or buy drugs. There is a BIG difference. Everyone is not and addict. I’ve been sober from alcohol for 22 years and it was a really hard decision for me to make to have to go onto these drugs. I talked to many people in recovery, I talked a meetings. In the Big Book it says sometimes we have to take certain medication but as long as we take them exactly as prescribed we are still sober. In 22 years I have taken my medications exactly as prescribed because my sobriety means that much to me. And this year, I called at least 30 different pain management offices and 80% of them had no room for new patients because of the new laws so now I have no meds and I’m a candidate who’s going to be bedridden and in terrible pain for months because I’ve given up on calling doctors with all these freaking new laws. So thanks. Thanks for helping the war on drugs in the wrong place so you could cover up how bad it truly has been in the streets for at least 15 years with massive amounts of pain killers being sold. I really don’t want to leave my name and email in fear that you’ll put me on some kind of bad list or something. But I’m so fed up I finally had to speak out.

2000 Double Laminectomy with Titanium Cages inserted at L/4-L/5 L/5-S/1 this surgery following 3 years of every alternative treatment modality known in that time. Pain management was first on the list. When I first went into pain management the doctor there was only interested in getting me a set of 3 epidural steroid injections and writing pain medication prescriptions. Ill never forget the day they walked into the exam room and the doctor asked what I was currently taking for my pain. I told him Hydrocodone (which I was doing fine with) The doctor and nurse both chuckled and the doctor said to me :” well we only use the big guns here, we will have to discontinue the hydrocodone today that’s only for short term use. The prescription I walked out with was Fentanyl Patches and MS Contin for breakthrough pain. The fentanyl nearly killed me as my wife found in bed that afternoon in a pool of drool unresponsive. It took her dragging me in the shower and running cold water over me to get to come around . As I came to I immediately ripped off the patch and cursed the doctor for giving an naïve opioid user fentanyl patches for two herniated discs. I called the doctor the next day and told him what had happened and he told me he would write me a prescription for something milder. I asked why I couldn’t just stay on the hydrocodone it was working fine and I was able to still go to work. He refused So I left his practice and sought out a new pain doctor. The new doctor was just as intent on taking me off the hydrocodone so I left his practice it wasn’t until the 4th pain management doctor who allowed me to remain on hydrocodone but added Soma to my regiment. This all took place from 1999-2002 when I had my first surgery. It fixed my locked up aching back but caused scaring of the nerves and radiculopathy into both legs and feet the made my old back pain feel like a day at the beach. In 2003 I had the Texas Back Institutes top spine surgeon do a revision surgery to stabilize the fusion site. Following the surgery on the day of discharge I began to hemorrhage profusely from the surgical site and was rushed back into the ER for a third surgery to clean out the surgical site of a staph infection. I remained in the hospital on IV antibiotics for 5 days following that surgery. And beknown to me at the time I developed Adhesive Acharoinditis along with that infection cleansing surgery. Know my pain was excruciating but it was still being called radiculopathy and post laminectomy syndrome an intractable pain condition that required around the clock opioid therapy to control the pain. This was in 2003 I enter pain management permanently as there were no further surgical options. And the prescribing n 2003 was very liberal. there were only every 3 or 4 month visits necessary.. No urine drug tests, very compassionate doctors and no one looing down there noses at you with skepticism. And the point was driven home at every visit , “Don’t ever let your pain get out of control, that’s what the breakthrough medications are for”. A complete 180 from todays super paranoid prescribing policies and uncompassionate doctors who look at you with a look of skeptismn first until you can prove your legitimacy.
So here I sit today in 2018 with 4 intractable pain conditions, Complex Regional Pain Syndrome in both lower legs and feet, Adhesive Arachnoiditis at the L3/4 level, L3/4 bi-later radiculopathy chronic, L4/5 -L4/L5 -L5 /S1 radiculopathy chronic post laminectomy syndrome, intractable pain syndrome and s list of other conditions all caused by the butchering of my spine during the first surgery and the dozen or so steroid injections I received in my spine from pain management doctors as a way to supplement their incomes. I never received one days worth of relief from any steroid injection I ever received yet was required to get them in order to become a patient at any pain management clinic. And today I am lucky if I can find a pain management doctor who will even take me as a patient because now I am labeled with an Opioid Use disorder because I’ve been prescribed Opioids by my doctors for nearly 20 years yet I get the label of having a substance use disorder. Where is the fairness in that and what label is pinned on the doctors who prescribed me all of these drugs for 20 years are they label Opioid Prescribing Disorder Doctors, of course not, they go about their business as usual unscathed and untouched by the 180 degree turn in Opioid prescribing policy while I a 20 year user of these drugs am forced to get off of them and writhe in agonizing pain that no other modality will even touch in dulling the pain. This country and its stance on the Opioid Crisis that has nothing to do with pain patients is on the level of Genocide and torture of its own people at the hands of its government. If Mr. Donald Trump passes his Medicare policy in 2019 further restricting the availability of Opioids to non cancer patients there will deaths untold and agony and torture of hundreds of thousands of baby boomers who have lived though the two worlds of pain management and are their ones who will pay the ultimate price with their lives because of American politics practicing medicine in this country.

I have been sent to specialist for Neuro and been misdiagnosed..c3-4c c5-6 fuzex. 1yr later sent to another doctor who found problem. I had a blockage due to having Chiari type 1. He proceeded to clear blockage and took too much off causing 4CFS leaks and need for shunt. I have had 5 shunt revision since 2015. Just had lower back surgery past December have been right Fluid leak in back that was fuzed 1-7 with stabelization bars. Going back in surgery April 5th 2019. Now im red flagged due to massive narcotics use. I went to med clinic and nurse didn’t do her part and threw me under bus. She was suppose to tell my therapist to send monthly statements and didn’t I kept seeing him on my own. Wasn’t told had to go back but wanted to on my own and did and still do biweekly. Due to her incompetence I’ve been let go and now primary of 20yrs as well. Saying I didn’t comply with rules. I’ve done nothing wrong

Brian,
Great question and I look forward to others responses. You have pointed out one of the huge problems that exist. Addiction rates are sky high and treatment centers are few, underfunded, and require commitment. That being said it starts with a conversation. Personally that is not the patient I am seeing. I see more of the older adult that doesn’t even realize they are addicted or often understand what these drugs are.

Excellent post, Dr. Flynn. I was actually just talking about this very subject with my wife a couple of nights ago. Not only has prescription opioid use become a huge problem in and of itself, it has been suggested that it is potentially a gateway toward heroin use/addiction. I just recently read a 2012 paper by Michelle Peavy and colleagues in the Journal of Psychoactive Drugs that sought to determine what proportion of heroin users started with prescription opiates. While this study was not the greatest from a methodological standpoint, it did present some preliminary information from which more robust research can done. I didn’t have time to do a literature search for studies done since then so there may already be more up-to-date information on this. Regardless, I think this opioid crisis demonstrates how important our role is, as PTs. Given that the information is out there that PT first beats surgery and reduces opioid use, it is more imperative than ever that we as a profession establish more standardized care and decrease the variability of practice that our patients so often encounter. We are at a critical juncture indeed. Thanks for posting!

Standardize our care? As if we, as sufferers of chronic pain, are interchangeable and our needs all alike? Yes..opiods are gateways to street drug abuse WHEN the patient’s pain is not effectively managed. Of course, there’s also severe depression and suicide when the pain exhausts and overwhelms the sufferer. This is what happened to a dear friend of mine when he could no longer cope after enduring years of constant, inadequately treated pain.

We’ve been here before and have persecuted and prosecuted everyone and anyone who takes opioids-Didn’t work then and won’t work now! Learning seems to have amnesia when it comes to past prohibitive policy. Witch hunts don’t help! 100 million ppl suffer with chronic pain but no one is addressing that statistic, only addiction, which is mostly heroin (like it or not) If the medical profession continues to agree with failed policy, chronic pain sufferers will be the victims, once again

This is just chapter 99+ in the governments failed drug war. I am caught between needing pain medication -OR- going for a medical retirement. I can work and do when I can get medication. Now my oncologist has flagged me as ‘opioid dependent’ based on a conversation where I ASKED him to take over my pain management from the VA, and now I am waiting for the other shoe to drop. It is absolutely absurd to think I may be forced to take a medical retirement over big government overreach. I still can get by quite nicely without pain medication when NOTHING is expected of me, but I would prefer to work, and it would seem most logical that society would be better off keeping tax payers productive and fully functional.

Would I choose addiction to pain medicine and being able to function ie., hold a job, perform job responsibly, participate in family functions, have a relationship w/ daughters, aging parents, worship at church, plan for my future….have what most people take for granted as a normal life?!! What would YOU do? Without my medication I would have no ability to function in any aspect of life. The pain is too much to bear physically and mentally. Hell, I have extreme difficulty even cleaning myself after using the bathroom due to the stress it puts on my spine! Im not saying this to shock but to tell you a REAL task that I must deal with daily while most take this for granted. What would you choose?! What kind of choice is this? Would you have your mother/father, siblings, or child live like this? Think about it before you judge.

I am surprised not one statement on Suboxone?
I was on Fentanyl morphine soma and klonopin after having surgery to have plates and screws put in at C3 C4 AND C5, then I broke my clavicle followed by my shoulder TWICE!. I was a mess. Quit my job, basically quit life.
Suboxone doesn’t get me high and from what I recall it never did even though those days are hazy for me.

I was in a bad relationship and without going into detail came back down to Texas from NH overnight. Didn’t know much about addiction just thought I could stop. Omg it was horrible. What made it worse was all the AASPEAK about ‘craving’. Over and over i was told your shaking, delirium, vomiting and pain is just ‘cravings’
BULLSHIT! when I was pregnant I had cravings. But if they weren’t fulfilled it did not affect me physically -maybe it affected my husband who had to put up with me punching him for not giving me what I want but i wasn’t going to physically suffer.. A craving is a psychosomatic affliction. Withdrawals are not in my head ! If you are vomiting A LOT perhaps with the flu and someone gives you donagel, you didn’t CRAVE donegal. You just didn’t want to be sick. If you have a fever or headache and aspirin would take it away are you really just craving aspirin?
So yeah if an opioid stopped the terror of DTs, I am not ‘craving’ opiates. I just dont want to feel this awful. If someone told me “ya know what? eating dogshit stops the shaking, sweating, vomiting and night sweats”, I WOULD GLADLY EAT DOGSHIT! So stop with the’ CRAVING’ it’s ridiculous.

I found a superb doctor who accepted me in the program , started me on Subutex followed by Suboxone sublingual and I have not looked back for 8 years . and get this, it has the added bonus of my not being able to get drunk.

I dont ‘crave’ – (which it’s actually applicable here) narcotics of any kind.
Even on narcotics I craved MORE narcotics. On suboxone that desire is gone

So why aren’t people going this route? And why are the programs so difficult to get into? I honestly do not get high yet my sub doc is constantly on edge because these assholes who aren’t even doctors are dictating how he practices medicine.

It is up to the doctors to stop this. they need to band together and show up at every instance where this is being deliberated and fight to keep the government out of our personal business.

It is doing more damage and making street peddlers more and more revenue. I would not doubt the powers that be are being manipulated by the street drug trade because they seem to be the only ones not opposed to this ridiculous invasion of privacy

Too much focus Dr. Flynn on how to keep and take “opiates” away from patient and not enough on the patients wellbeing. Googled and found this article while trying to research information after being diagnosed with cancer. Thyroid cancer then cervical neck x 2 and now the newest guest breast cancer. Pain level, they never ask anymore when I go to my doctor , they do not want to know! And I do not want to tell them anymore because they cant help me anyway and this is why I am refusing cancer treatment. I will continue to be in pain anyway and the treatments just make me sicker. Being red flagged has caused me to suffer neglect at a hospital in December 2018. Several people over the past 2 years have took their own life due to pain and I see nothing wrong with it, no judgement. Maybe there needs to be a bigger movement toward assisted suicide and opiate patients in chronic pain given the option. I would take it right now!! We make this living and dying thing so hard…